I was intrigued to see that Ron’s lunch consisted mostly of plant foods which he ate avidly; he said he believes that most people on his diet eat a significant amount of plant foods. I came away with the impression that the Rosedale Diet resembles the ketogenic version of PHD, only with less starch and MCT oil.

One of my objections to Ron’s recommendations has been that very low carb and protein consumption can be stressful to the body. Scarcity of carbs and protein invokes certain starvation-associated pathways – for instance, lower T3 thyroid hormone. We discussed this in “Carbohydrates and the Thyroid,” August 24, 2011.

Ron believes that low T3 on low-carb diets is healthy, and other low-carb advocates, such as Sam Knox, have made similar arguments.

I believe that intermittent fasting, which invokes starvation-associated pathways transiently, is usually health-improving – but that you can overdo it. What happens if you invoke these pathways chronically and continuously?

Prof Dr Andro on the “Athlete Triad”

Some light was shed on this question recently by Adel Moussa, aka Prof Dr Andro, who discussed the “athlete triad” in three posts (Part I, Part II, Part III) at his blog Suppversity.

The athlete triad appears most commonly in athletes who undereat and overtrain. Symptoms include low energy, amenorrhea in women and low testosterone in men, osteoporosis, reduced cognitive ability, and impaired immune function. The syndrome is surprisingly common, especially in female athletes:

Although the exact prevalence of the female athlete triad is unknown, studies have reported disordered eating behavior in 15 to 62 percent of female college athletes. Amenorrhea occurs in 3.4 to 66 percent of female athletes, compared with only 2 to 5 percent of women in the general population. [1]

As Adel discusses in Part II, the athlete triad is characterized by the following hormonal pattern:

low estrogen and testosterone levels

low T4 and low T3 thyroid hormone levels, often with low TSH and high reverse T3

a disturbed circadian cortisol rhythm lacking an appropriate cortisol spike in the morning and a normal decline in cortisol levels in the course of the day

low leptin, low insulin, and low IGF-1

Precisely the same hormonal patterns, including lower thyroid hormone levels, higher cortisol, and a suppressed circadian cortisol rhythm, are observed in total fasting and starvation. [2] [3]

These hormonal changes conserve glucose and protein, an appropriate step during starvation. The energy-intensive tasks of immune function and reproduction are temporarily suppressed until energy is more readily available.

Similar patterns of reduced T3 and elevated cortisol excretion were recently seen in a clinical trial of a 10% carb weight maintainance diet. [4] This trial shows that even in the absence of calorie restriction, carb restriction is sufficient to reproduce much of the “athlete triad”/starvation hormonal pattern.

This pattern reaches its most extreme form in anorexia:

[H]ypocaloric diets causes changes in thyroid function that resemble sick euthyroid syndrome. Changes consist of a decrease in total T4 and total and free T3 with a corresponding increase in rT3….

States of chronic starvation such as seen in anorexia nervosa are also associated with changes in thyroid hormone, GH, and cortisol secretion. There is a decrease in total and free T4 and T3, and an increase in rT3 similar to findings in sick euthyroid syndrome…. [T]here is an increase in GH secretion with a decrease in IGF-1 levels…. The changes in cortisol secretion in patients with anorexia nervosa resemble depression. They present with increased urinary free cortisol and serum cortisol levels. [5]

In chronic starvation, hunger is replaced by anxiety and a desire to move. In evolutionary context this urge to be active may have stimulated food-seeking, but in modern life it can exacerbate conditions like the athlete’s triad.

Chris Kresser: Back around 2000, I was interning for a holistic doctor down in San Diego, and this was before I got into Paleo or anything, and I was, I think, a vegan macrobiotic, for crying out loud, at that point! So, we had a patient who was just really, really sick, and he was just getting sicker and sicker. He weighed about 90 pounds. I think he was about 6 feet tall. And the doctor had him on a restricted diet, you know, one of those food allergy type of diets where all you’re eating is, like, broccoli, venison, and quinoa.

Kurt Harris: The Specific Carbohydrate Diet?

Chris Kresser: No, no, just like a really, you know, they do the IgG food testing, which is kinda bunk anyways.

Kurt Harris: Yeah, that’s pretty bunk.

Chris Kresser: And then they find out you can only eat strawberries, broccoli, quinoa, and ostrich! You know? And so, he was doing that, and he kept removing foods until he was literally down to, like, broccoli and steamed whitefish or something. That was all he was eating. And he just kept getting sicker and sicker. So, he disappears for about six months, comes back a completely different person. He’s back up to 160 or 170, which was his normal weight, you know, completely normal complexion. Literally, we didn’t even recognize him, and the doctor was saying: What happened? Was it diet? And the guy was like: Yep, it was diet. And he said: Was it the candida diet? Was it the Specific Carbohydrate? What was it? And he said: It was the beer and pizza diet! [laughter] And this guy literally, I mean, the guy got to this point where he was like: OK, if this is my life, I’m fine with just flaring out. You know, this isn’t worth it. And if I’m gonna go out, I’m gonna have fun. And so, he started going out. You know, he wasn’t ever hanging out with his friends anymore because he was on such a restricted diet, he had no social life, so he just said: Forget it. I’m gonna drink beer and eat pizza at least three times a week, and then the other times I’m gonna do whatever I want. And that completely restored his health.

Adel speculates (very plausibly in light of the man’s weight of 90 pounds!) that the patient was suffering from the starvation pattern which is replicated in very low-carb “euthyroid sick syndrome” and the athlete triad. What he needed was more calories, especially carb and protein calories. Pizza and beer are great sources!

Conclusion

It was a pleasure to chat with Ron and Dr Mercola in Chicago. We recorded a four hour discussion, which is going to be edited down to an hour or hour and a half.

We found plenty of common ground. We agreed that there are very real health benefits to low-carbohydrate diets. Low-carb diets are helpful against diabetes and metabolic syndrome, and quickly improve cardiovascular risk markers such as blood pressure, triglycerides, and HDL.

But in biology, good things can always be taken too far. One can restrict carbohydrates (and protein) too much. Extremism in carb restriction may, indeed, be a vice.

Amen to that! There are a lot of passionate people in the paleosphere, and this sometimes comes across as very angry/obsessed people (I won’t mention which sites). Interesting post, Paul. I look forward to the new book!

I can’t tell anything from the numbers alone. T4 and reverse T3 are high, T3 a bit low, TSH normal. This could be consistent with any pattern from normal thyroid, hyperthyroidism, or hypothyroidism. Do you get adequate selenium which is needed to convert T4 to T3? Other cofactors like copper and magnesium?

I felt like he was reaching for common ground. He agreed that glucose is a nutrient that cells need, but argued that it’s better to manufacture glucose from other substrates than to eat it. He also agreed that we should eat more carb than protein.

What I hadn’t realized before is that he sort of assumes that everyone will eat some carbs, and so though his advice is geared toward minimizing carbs and treating carbs as a poison, maybe that shouldn’t be taken quite literally.

So I wouldn’t necessarily say that he changed his position, but I understood his position better and he moderated some of his language.

I did enjoy our exchange in Chicago. Please let me correct your mention above about what I had stated concerning carbs and protein. I had said that both (non fiber) carbs and excess protein are detrimental, but that perhaps excess protein is worse than some clean starches. I was stressing how bad high protein is.

Also, I do and did recommend lots of coconut oil/MCT oil.

On T3; I do believe that lowering T3 into the low normal range (without concurrent elevation of TSH, not just “low T3”) as done by my diet is a great sign of transforming into a very healthy phenotype similar to what is seen in centenarians and calorie restricted animals.

As far as our lunch at the venue, I had a fine salad including chicken, as that is what was offered (and had no starches, of course).

I thank you for continuing to participate in our discussions to advance people’s education.

You are vey welcome. Lunch was quite good. We had made a comment that we liked avocados, so Joe kindly provided lots of them the following days. Some avocados and/or almonds on the salad (with chicken) that we had would have added some good fat and made it even better.. Thanks again for sharing..

1 – Over training is not carb restriction and is unhealthy on any diet.

2 – Nutritional ketosis is not even remotely the same thing as starvation, starving people are dying, many in nutritional ketosis are THRIVING (and athletic).

3 – See 2

4 – Not a properly constructed ketogenic diet, guaranteed at 10% carbs, 60% fats to fail and put the subject in low carb limbo. This is the most common mistake made on ketogenic diets and the use of blood ketone meters is demonstrating that perfectly now that daily measures are affordable.

Additional 3 weeks is not long enough for real adaptation, guaranteeing a group of the trial participants would not do well.

Additionally reduced lab markers are normal and expected in true nutritional ketosis, which is an entirely different metabolism – no mention was made of actuay hypothyroid clinical manifestation. This is a common misunderstanding of low carb research and a fail in that A to B and B to C does not mean A leads to C.

Each study sort of proves nothing on its face about a properly formulated ketogenic diet because the intervention did not actually use a properly formulated ketogenic diet. 2 were starvation studies which deprive the body of all nutrients not just caubs.

I am still waiting for some real science on this that can pass the sniff test of a skeptic.

Nowhere do I say that all of these health conditions are identical. Clearly total starvation is worse for you than carb restriction.

The common element is a hormonal pattern that tells the body to reduce its utilization of glucose and protein when their intake falls short of the body’s normal utilization.

Whether the shortfall is brought about by very low-carb dieting or by arduous exercise (which increases glucose utilization) may lead to significant differences in health outcomes, or may not.

I don’t know why you bring up hypothyroidism. Nobody said anything about that. I did mention “euthyroid sick syndrome.” “Euthyroid” = healthy thyroid = not hypothyroidism.

It’s funny that you demand “real science” from others but are content yourself to defend your diet with unsupported and hard-to-interpret statements like “nutritional ketosis is an entirely different metabolism.”

The reality is that many aspects of very low-carb diets have not been tested in clinical trials, or when they are the diets are said to be “not properly formulated,” so the evidence we have to work with is to a large extent composed of personal experiences and analogous situations such as the athlete triad.

Hi Paul. Heard you in York, Maine, bought the book and read cover to cover. Unfortunately, I am now diabetic and even a small amount of rice or starchy food sends my blood sugar sailing. I am very interested in your take on Ron’s work (have read his book) Nora Gedgaudas position, and the work of Natascha Campbell-McBride. I know my thyroid hormones are off, and my NP has me on a 30mg compound with ginger. When I held it for a while, my serum albumin dropped this spring. I am eating more like Ron these days, having issues dropping the protein and upping fats without dairy (it doesn’t really agree with me). I do use coconut oil liberally. If you have a design for a diabetic to tolerate more carbs, let me know. Even a little carrot sends me up. I keep hearing ketosis is the way of our forefathers. Best to you and Shou-Ching.

It’s a big complicated to address personal issues like that, because everyone’s case can be a little different. I tend to associate those blood sugar regulation issues with small bowel infections such as SIBO. These are not always easy to diagnose or treat. There are other issues too that can contribute, eg nutrient deficiencies like chromium or magnesium or copper or iron.

I think eating VLC can be a good stopgap for diabetics while you sort out problems. Your liver may be making extra glucose from protein, so you may not need as much dietary glucose in any case. But I think it’s important to address as many health issues as you can, and then when glucose regulation is better, to restore a modest amount of carbs.

As you know from my posts on syontix.com, I fear people are risking endotoxemia by failing to eat in a way that preserves their gut barrier function and beneficial gut flora populations.

What strikes me when I read through a lot of the comments on Paleo or Low Carb websites, are the large numbers of people battling GI issues. This is telling me something is seriously wrong. As many of these people started eating this way to correct preexisting health issues, this leads me to believe they’re not doing themselves any favors by replacing fat phobia with glucose phobia.

For example, if they already have an undiagnosed case of small intestinal bacterial overgrowth and begin a very low-carb diet that impairs the replenishment of the intestinal “sugar coat”, they risk increased translocation of gram-negative bacteria into systemic circulation with all the inflammatory and hormonal changes that brings. However, even in the absence of SIBO, they still risk translocation of gram-negative bacteria from the colon, especially if they already suffer from colonic dysbiosis which many of them do.

Given what we now know about how lipopolysaccharides impact the hypothalamic-pituitary-adrenal axis and tryptophan/serotonin/melatonin levels, this explains a lot of the symptoms observed.

Thank you for injecting a necessary corrective to this very low-carb mantra and encouraging the consumption of safe starches.

Thanks. As you know deficient production of mucus (and probably glycocalyx and other protective glycosylated proteins) is one of the “zero-carb dangers” I’ve blogged about. Appropriate production of these is important for a healthy digestive tract. Thanks for emphasizing this point, and for your recent blog posts on gut health.

I still wait to see some real evidence about “deficient production of mucus” which you repeat over and over again.

Personally, I bet its not about carbs at all, but about other numerous changes people do when entering such a radical life style change – for instance, not enough fat (or quality fat), not enough offal or supplements.

Or simply, and IMO most probably, not enough of vitamin A since there are bunch of scares and misinformation people have about it while paleolithic “doses” were calculated to be around 8k IU / day. Andro also rightly pointed about a problem with beta carroten labeling as vitamin A. IVAC, the most qualified group that researched most about it expressed that maintenance dose should be 25-30k IU/day for all apart from reproductive females.

Paul, It’s so refreshing to see scientific folk debating the facts rather than engaging in personal attacks that are a complete waste of time. Kudos to both you and Dr. Rosedale. If only everyone would follow your lead (I know, it will never happen). One factor that I think tilts in your favor is hormesis. Simply following a zero carb diet and not occasionally, intermittently and randomly consuming carby foods foregoes the potential benefits of hormesis. Another factor in your favor ironically comes from a VLCer–Tom Naughton’s quote that “Let’s start with one simple idea: Mother Nature isn’t stupid. She didn’t make human beings the only species that prefers foods that will kill us.” The idea that nature has carby foods that taste delectable to us humans but are horrible poisons makes no evolutionary sense. Thanks for your efforts and please keep up the good work.

I agree, in fact the first part of our new Scribner edition is about various lines of evolutionary evidence for the optimal diet, and one of them is our attractive taste for sweets and carbs generally.

Thanks, Phil for the kudos. As far as Tom Naughton’s ascribed quote above and your reference to it; yes, Nature is not stupid, but she cares about different things than we do. As such what does not make much sense to us, can make perfectly good sense to her. I think I will write a blog post about just this evolutionary subject. Thank you for the fine comment.

It’s true that Nature doesn’t care if we live to 90 or become elite athletes or other modern goals. Looking forward to your post, Dr. Rosedale.

Interesting that you see coconut oil and avocados as healthy. I’d be interested in your thoughts, either here or in your post, on the evolutionary explanation for their healthiness vs. not so much for sweet fruits and tubers. I have heard of traditional cultures preferring fatty fruits and nuts to sweet fruits (though I think fatty fruits are rarer than sweet fruits and many beyond avocados and coconuts appear to require or be more edible with significant processing or cooking), so perhaps that’s part of it?

As a species, humans are already a species that have been selected (through evolution) for longevity. You need only look at other primates to know this. Whether a diet that minimizes fructose and glucose leads to this we need more studies.

Baring major illness/environmental poisons/lack of vitamins/minerals/micronutrients. I do not feel diet will lead to large increases in longevity (maybe 1-2 years, baring the above problems). Mice and other critters have definitive pathways that get activated from fasting or sugar restriction. I bet humans have already a lot of these longevity genes activated. Of course, you can’t be overweight and eating processed foods devoid of nutrients and still hope to be healthy.

I’ve been on longevity boards for years. I think its more important for us to work on the remediation of aging vs the optimization of the aging process. (Are the majority of people ever going to just forgo deserts and the happiness they bring?) <— moderation on the smaller end of it really works and is not quasi science.

Paul, I’m a big proponent of your dietary approach, and I wonder if you have any comments for people like me who would LOVE more starch in their diets, but have only found symptom relief by following the Specific Carbohydrate(TM) Diet, which is mostly starch-free (right now, even some of the “legal” starchier foods, such as ripe bananas, are beyond my reach). Things are definitely getting better, but I might be stuck on this diet for awhile.

I have seriously wondered if there’s a way to get starch into my body from the other end! Any comments?

I’m guessing the symptoms that are troubling you are IBS or ulcerative colitis?

It’s not bad to get carbs from sugars in such conditions rather than fiber-rich starches. Dextrose powder or tapioca syrup might be possible sources of glucose that won’t disturb the colon; as Ray Medina mentions above, sufficient carb intake may be important for gut health and IBS recovery. Also fermented vegetables may help with gut recovery.

It takes time to heal the gut, so I’m glad to hear things are getting better for you!

This sounds interesting, am I understanding correctly that doing an SCD or GAPS protocol plus some dextrose powder or tapioca starch would make the diet PHD compliant? The added glucose could help restore the intestinal mucosa? (I happened to be VLC when I developed UC)

Yes, that’s a relatively safe way to get your carb intake up on SCD/GAPS, and you don’t want to be carb deficient as that increases the risk of compromised intestinal barrier leading to problems like UC.

I know I’ve said it before, but I.think its important. I have terrible ibs probably crohns that I help put in remission with fructose containing carbs. I tried ketosis and got worse, tried starches got worse, tried brown rice syrup, plain dextrose close but still not there… Tons of white sugar and ripe pineapples really helped turn the tide when added to my phd diet of gf meat, organs, gelatin. Interesting huh?

Hi,
I’m sorry for the off-topic post. I just wanted to say that I really admire your work (the book and the website) and I started following your dietary advice in order to rid myself of some health problems. Thanks to your work I’ve been feeling much more confident about what a healthy diet should look like, but just a few days ago I stumbled upon this (very long) video series on YouTube which have made me completely confused and insecure about everything again, because the maker of the video’s makes such good points against not only Paleo, but also against the Perfect Health Diet. Has anyone on here seen the series? Do you have anything to say about it? I just want to hear anyone explain to me that this guy is just dead wrong…

I looked at some of the videos when they came out. They had a low density of information so it was rather tedious. I don’t recall exactly why I decided it wasn’t worth responding to. Perhaps engaging the vegan arguments and critiques of Paleo/PHD would be a useful exercise.

I’m not sure I’d describe myself as a “low-carb advocate”, but this particular criticism of low-carb diets is unwarranted.

Even if it’s true that stress in the form of overtraining, starvation, or serious illness causes a reduction in blood levels of T3, it doesn’t necessarily follow that all reductions in T3 are caused by stress.

One of the functions of T3, along with insulin, is metabolizing blood glucose. It shouldn’t be surprising, then, that a diet that lowers blood sugar also reduces the need for both T3 and insulin, and for the same reason.

More importantly, in the 30 years or so since the connection between dietary carbohydrate and blood levels of T3 was established, there has emerged not a single piece of clinical evidence that the reduction in T3 that accompanies low-carb diets has any adverse effect.

So, my argument is simple: There is an obvious, plausible, and benign explanation for the reduction in T3 that accompanies low-carb diets, and no evidence at all that it causes any harm.

To be perfectly honest, and with all due respect to you, I think this has ceased to be a scientific debate. It is simply unethical for you and others to continue to promote an idea that might influence the behavior of others that has neither theoretical or empirical support.

And something to consider is that in the case of the athlete examples or low calorie intakes, metabolic rate is slowed over time. With carb restriction itself, to ketosis, metabolic rate is usually shown to increase, despite a t3 decrease. So it’s not like carb restriction leads to an overall starvation, low calorie conservation of energy–just glucose conservation.

Yes, withdrawal of glucose from the blood by cells is regulated by T3 — more T3, more glucose utilization by cells. My point is that like all things in biology there will be a U-shaped curve of healthfulness versus rate of glucose utilization, so that either too much carb intake/T3 or too little will be deleterious to cellular health.

It’s not enough to say that since the T3 level is properly matched to the dietary carb intake, that all is well. That begs the question of what the optimal carb intake (T3 level) is.

I’m not sure what you’re counting as “clinical” evidence. Chris Kresser has built a big part of his clinical practice on people have trouble with low-carb Paleo. There are hundreds of people who have had these experiences. This is empirical support. And I’ve presented theoretical support in my blog discussions.

I’ll go even further than Sam and suggest that in reality no one has the slightest idea what any particular person’s T3 level should be (apart from the need to avoid obvious pathological extremes of course).

My own endocrinologist, with many years of experience exclusively treating hypothyroidism with combined T3/T4, stopped measuring T3 (and reverse T3) years ago for this reason. Despite all his efforts to use the information, it never turned out to help him make better recommendations for individual patients. It was just noise, and it could be very misleading.

For example, a patient feeling poorly with a “low” T3 test result would beg for more T3. But that approach doesn’t work. Too much T3 supplementation is as bad as not enough, and plasma T3 levels provided no basis for judging the dose in any given case.

If Chris Kresser has patients who feel poorly and are on low carb diets then maybe the low carb diet needs troubleshooting. Maybe the person even needs some more carbs. Maybe the problem lies elsewhere entirely. But I very much doubt measuring T3 levels will be helpful in figuring it all out.

Using T3 effects of low carb diets as a basis for theories about how to eat is not convincing, either, whether Ron or Paul makes the argument in different directions.

As my endo says, forget all the noise, stop doing uninterpretable tests, and just experiment until you find out what makes the person feel and function better.

Should one of the many people who feel great on VLC and have “low” T3 start eating carbs to treat a lab result no one understands? Or vice versa? We’re a very, very long way from the ability make such connections, IMO.

You mentioned that both high carb and high protein diets are detrimental to longevity. So my question is what remains – high fat diet? How much fat can one eat?

Another question. You mentioned that in the past you were probably on zero carb diet due to eating only vegetables as the source of carbs and they have none. How come? Every vegetable has some amount of carbs?!

this is interesting. so does it mean that non-starchy vegetables do not have much nutritional value except some vitamins and minerals?

if you don’t mind, I have some questions regarding my readings of Ray Peat. First, if my pulse is normal but the temperature is rather low, often around 36 C, does it mean that my thyroid is off? Second, according to Peat not only omega 6 is toxic but omega 3 as well. Do you yourself recommend supplementation of omega 3?

Paul, so if I don’t eat much starch, but 1 large serving of fruits a day, could it be considered a low carb diet? I never thought of it in this way. Fruits are digested very fast, so their load of glucose for the liver would be soon exhausted. That;s why starches make us feel full much longer.

But the main take away I took from it was the stressful result of eating such a restrictive diet coupled with the detrimental psychosocial effects of not seeing one’s close friends? Not so much of the dangers of eating VLC. How I came to that thought was the subject on how silly it is when those that believe all physical and mental health stems from solely diet.

Great point that stress and lack of social contact can significantly impair health. I think though that losing weight down to 90 pounds (!) shows it was starvation that was his main problem. Stress and disrupted circadian rhythms from lack of social contact will tend to produce weight gain in most people.

I am currently on the GAPS diet, and have seen AMAZING results in my emotional/psychiatric problems. However, I’ve been doing it VERY low/no carb (NO fruit, NO squash/carrots, NO nuts, NO coconut flour) because I feel that it is necessary for the emotional benefits (basically avoiding yeast flares I think). However, I most definitely have nearly every symptom listed on StopTheThyroidMadness.com (honest, I do), and so I am concerned about harming my thyroid more by being in starvation mode. (Eating tons of fat.) My question for you is this: How does one choose between depriving systemic yeast of food while providing the thyroid food (glucose)? Your thoughts would be much appreciated.

As an additional note, I have always been very thin. But since starting GAPS, my upper body–arms and bust–have continued to remain very small–in fact they’ve probably wasted away a little more–and my lower body–belly, buttocks, thighs have started collecting fat. What do you say to this? I thought eating fat was supposed to make you loose fat. Hormone/metabolism problem?

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I have the same problems as these female athletes but I got the blood tests done before I went low-carb. I also had shigella toxin which I never would of thought because my only symptom was a few days of diarrhea–I figured it was mild IBS. I’m taking DHEA and and adrenal supplement to bring my morning cortisol up. Not sure what I did wrong to have all these problems at 24, but I def went wrong somewhere!

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